Hospital emerges as epicenter of Riyadh MERS outbreak

A quickly growing MERS-CoV outbreak in Riyadh, Saudi Arabia, involves one main hospital, King Abdulaziz Medical City, with at least 31 illnesses since June linked to emergency department (ED) exposure, officials say, and indications of many more to come.

Also, the country announced 10 new MERS-CoV (Middle East respiratory syndrome coronavirus) cases today, 9 in Riyadh likely linked to the hospital.

Saudi Arabia's Ministry of Health (MOH) started announcing a steady stream of MERS cases at the end of July that has accelerated in recent days, with hints over the past several weeks that healthcare and family clusters are involved.

Updates from the World Health Organization (WHO) over the past few weeks have fleshed out some of the hospital exposures, and an update today on 12 Saudi patients revealed that 4 got sick after visiting the ED and 9 acquired MERS-CoV during hospitalization for unrelated conditions at a facility undergoing an outbreak.

Main hospital revealed

Peter Ben Embarek, PhD, who leads the WHO's MERS response, told CIDRAP News that the vast majority of recent and current cases are related to one hospital, a national guard hospital in Riyadh. He added that there is a small outbreak at another hospital involving five cases, as well as sporadic cases not linked to the main hospital.

Ben Embarek said the smaller hospital outbreak is under control.

King Abdulaziz Medical City has about 690 beds and was established in 1983 to care for National Guard soldiers and their families. The government-funded hospital was combined with many other medical centers and inaugurated as a "medical city" in 2001.

King Abdulaziz Medical City said in an Aug 15 press statement that 31 MERS-CoV infections have been reported in people who visited the facility's ED between June and Aug 14. Dr Hanan Balkhi, the hospital's director of infection prevention and control, said in the statement that, in addition, 4 healthcare workers have tested positive and are in home isolation.

The hospital said a number of suspected MERS cases have also been reported and are under investigation. So far 12 deaths have been reported in connection to the outbreak, the hospital said.

In announcing steps to curb the spread of the outbreak, the hospital hinted that overcrowding in the ED may be a contributing factor, a pattern that also helped fuel the large hospital-linked outbreak in South Korea this spring and summer.

Balkhi said because of the rising number of MERS cases, along with around-the-clock large numbers of patients in the hospital's ED and difficulty applying quarantine measures, the facility will limit the number of patients in the ED and outpatient clinics. It will also suspend all surgeries that aren't urgent, suspend all same-day and short-day surgeries, and set aside special areas to quarantine suspected and isolate confirmed patients, including in the intensive care unit.

The hospital has limited visiting hours and has restricted the number of visitors and said it will reassess its control steps as needed. It said it is collaborating with the MOH on handling the outbreak.

Experts critique control measures

Ben Embarek said the WHO is in regular contact with the hospital and that different ways of supporting the country are being discussed, including a possible joint mission.

In February, a team of international health officials visited Saudi Arabia in response to a surge of infections in the country. They found critical data gaps on how and why MERS-CoV illnesses keep occurring in the community and how to improve prevention in hospitals and clinics.

One of the conclusions was that infections were still occurring in some healthcare facilities, but not others, a sign that infection control measures were effective, but not broadly implemented.

A similar joint mission to South Korea in June in the wake of its hospital-linked outbreak identified infection control lapses and complex dynamics, including ED crowding that was amplified by sick patients moving between hospitals. The team concluded, however, that overall the pattern resembled similar hospital-linked outbreaks in the Middle East.

Latest 10 cases

In other developments, Saudi Arabia's MOH today reported 10 new lab-confirmed MERS-CoV cases, one of them fatal, all in Riyadh. Investigations found that all but one had contact with a suspected or confirmed MERS case.

Two of the patients are foreign nationals, one of them a 35-year-old woman who is listed as a healthcare worker. The other is 71-year-old man who died from his infection.

Overall, patient ages range from 28 to 86. Five are hospitalized in stable condition, and four are listed in critical condition.

Also, the MOH said that an earlier announced patient died from his infection, a 71-year-old foreigner who had an underlying medical condition.

The latest cases boost Saudi Arabia's MERS total to 1,115 cases, 480 of them fatal. Currently, 42 people are still being treated for their infections, and 590 have recovered.

WHO on 12 recent cases

Meanwhile, the WHO today filled in more details about 12 cases reported by Saudi Arabia from Aug 10 to Aug 12. One of the infections was fatal, involving a 73-year-old woman who got sick after visiting an ED for an unrelated medical condition.

All but one of the cases is from Riyadh. The other case was reported in Abha in a 58-year-old man who has a history of contact with camels and consuming their raw milk.

Of the Riyadh patients, four got sick after visiting the ED and nine contracted MERS-CoV while they were being treated for other conditions in a hospital that has been experiencing a MERS-CoV outbreak. One of them, a 65-year-old man, was a contact of an earlier reported case.

Illness onsets for the 12 cases range from Jul 29 through Aug 8. Patient ages range from 45 to 99. Nine are men, and three are woman.  Nine of them are hospitalized in critical condition, and two are listed as stable.

The WHO also said that Saudi officials reported an additional death in an earlier reported case. Globally since September 2012 the WHO has received reports of 1,413 lab-confirmed MERS-CoV cases, with at least 502 deaths.

See also:

Aug 15 King Abdulaziz Medical City press release

Aug 18 Saudi MOH statement

Aug 18 WHO statement

Feb 23 CIDRAP News story "WHO notes stubborn MERS puzzles as Saudi cases climb"

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